Module 6:

Clinical Stage
and Grade

Introduction
Stage and grade determine prognosis
Staging reflects the clinical extent of the
tumor
Grading a tumor reflects its histologic
subtype
Of the two, staging is the primary indicator
of prognosis

Tumor progression
Tumors may occur spontaneously or
follow a series of cellular and tissue
changes known as epithelial dysplasia

Histologic alterations in
epithelial dysplasia

Enlarged nuclei and cells

Increased nuclear-to-cytoplasmic ratio
Hyperchromatic nuclei
Pleomorphic (abnormally shaped) nuclei and
cells
Increased mitotic activity
Abnormal mitotic figures
Multinucleation of cells
Keratin or epithelial pearls
Loss of typical epithelial cell cohesiveness

Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2nd ed.) St. Louis: Mosby
Neville, Damm, & Bouquot (2002). Oral and maxillofacial pathology (2nd ed.) Philadelphia: Saunders

Histologic alterations
observed in epithelial
dysplasia

Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2 nd ed. St. Louis: Mosby, p.
181

Architectural changes in
epithelial dysplasia

Bulbous rete pegs

Basilar hyperplasia
Hypercellularity
Altered maturation
pattern of
keratinocytes

Neville, Damm, & Bouquot (2002). Oral and maxillofacial pathology (2 nd ed.) Philadelphia: Saunders
Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2 nd ed.) St. Louis: Mosby

Carcinoma in situ
When the entire thickness from the basal level to the
mucosal surface is affected, the term carcinoma in
situ is used
Once dysplastic cells breach the basement
membrance and invade the underlying connective
tissue, carcinoma in situ becomes squamous cell
carcinoma
Term is used in case breast, cervical ca ,bowens
(squamous cell ca insitu

Neville, Damm, & Bouquot (2002). Oral and maxillofacial pathology (2nd ed.) Philadelphia: Saunders
Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology (2nd ed.) St. Louis: Mosby

Transition of epithelial
dysplasia to invasive squamous
cell carcinoma
Malignant cells
have penetrated
through the
basement
membrane into
the underlying
connective tissue
Sapp, Eversole, & Wysocki (2004). Contemporary oral and maxillofacial pathology, 2 nd ed. St. Louis: Mosby, p. 188

Grading
Degree of differentiation exhibited by cells
How closely cells resemble normal tissue
structure
Grade I low grade
Grade II moderately differentiated
Grade III poorly differentiated

Neville, B. W., Damm, D. D., Allen, C. M., & Bouquot, J. E. (2002). Oral and maxillofacial pathology (2nd ed.). Philadelphia: W.
B. Saunders.

Staging
Based upon the size and extent of
metastatic spread of the lesion
Tumor-node-metastasis (TNM) system
used for most cancers

Staging TNM
system
Size, in cm, of the tumor (T)
Involvement of lymph nodes (N)
Presence or absence of distant metastasis
(M)

Staging T
Size of primary tumor (T) in cm
TX

No information available on primary

tumor

T0

No evidence of primary tumor

Tis

Carcinoma in situ at primary site

T1

Tumor less than 2 cm

T2

Tumor 2-4 cm in diameter

T3

Tumor greater than 4 cm

T4

Tumor has invaded adjacent structures

Staging N
Lymph node involvement (N)
NX

Nodes not assessed

N0

No clinically positive nodes (not palpable)

N1

Single clinically positive ipsilateral (on same side) node

less than 3 cm

N2

Single clinically positive ipsilateral node 3 to 6 cm; or

Multiple ipsilateral nodes with all less than 6 cm; or
bilateral or contralateral nodes with none greater
than 6 cm

N3

Node or nodes greater than 6 cm

Staging M
Distant metastasis (M)
MX

Distant metastasis not assessed

M0

No distant metastasis

M1

Distant metastasis is present

TNM
Staging
System

Stage

TNM Classification

Tis N0 M0

T1 N0 M0

II

T2 N0 M0

III

T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0

IV

T4 N0 M0
T4 N1 M0
Any T N2 M0
Any T N3 M0
Any T Any N M1

Summary
Stage and grade of tumors indicates
prognosis
Treatment plans based upon stage and
grade, among other factors
TNM system used with most cancers